Leaving Slings and Other Transfer Devices Under Patients: A Clinical Decision Support Quality Improvement Project

The purpose of this quality improvement project was to develop guidance for safe patient handling and mobility efforts to prevent pressure injuries (PIs) within the Veterans Health Administration (VHA) when slings and other transfer devices are left under patients.

Health care staff (n = 112) in patient safety and nursing at 77 unique VHA facilities responded to surveys between November and December 2019. Interviews (n = 24) were conducted using purposive sampling with VHA staff at facilities with highest and lowest PI rates (n = 9) between January and March 2021.

Feedback on practices and perceptions related to leaving slings and other transfer devices were evaluated using online cross-sectional surveys and interviews with VHA staff. Secondary data for VHA inpatient rates of PIs were used to examine associations with staff-reported sling and other transfer device practices.

Leaving slings under patients was associated with higher proportion of patients developing PIs in intensive care units (ICUs, P = .042) and medical-surgical care units ( P = .025). In addition, use of sliding boards for seated transfer among short-stay residents in Community Living Centers was associated with higher PI occurrences ( P = .017). Qualitative interviews found perceptions and guidance about PI risk related to slings and other transfer devices varied among staff who consider many factors when determining risk.

There are perceived benefits and risks of leaving slings and other transfer devices under patients and limited knowledge of PI occurrences associated with this practice. Clinical decision support can help staff determine safe sling use. More work is needed to test the safety of common sling and transfer device practices and define best practices for communicating PI risk related to sling and transfer device use across the care continuum.